Journal of Analytical Psychology 1993, 38, 23-35 BORDERLINE STATES Incest and adolescence GEOFFREY N. BROWN, Bedford INTRODUCTION This paper is derived from my experience in the National Health Service setting where severely disturbed adolescents are treated on psychodynamic principles. For some time I have been interested in the-occurrence of borderline functioning within the adolescent phase of development, both as a manifestation of psychopathology and as characteristic of normal adolescent psychology. During the past few years an additional factor has emerged, alongside the more usual aspects of severe disturbance in adolescence, which has made a great impact on my own clinical setting, as it has on most others where children and adolescents are the focus of therapeutic attention. This new factor is a history of sexual abuse in childhood. In 1990 33 per cent of our new cases were known to be victims of past sexual abuse. Currently over half of the adolescents in the treatment programme have a history of child sexual abuse. This in itself is no longer outstanding. Most agencies working with adolescents have similar figures and in children’s homes esti- mates have been even higher. This change has produced a number of challenges: in clinical prac- tice, in interaction with other agencies, in interaction with families, and in the therapeutic relationship with adolescent patients. In this paper I will explore the impact of sexual abuse on develop- ment with reference to the adolescent life stage and provide some illustrative material from the therapy of a female adolescent patient. “Before proceeding with the case material, I will first refer to a paper by Briere in which he presented the results of a survey on a random sample of adult female ‘walk-in’ psychiatric patients (Briere 1984). He found that sixty-seven women out of 153 gave a history of childhood sexual abuse, and that these were statistically more likely to be taking psychoactive drugs, to have a history of alcohol or drug abuse, to have been the victims of battering in an adult relationship, and to have made at least one suicide attempt, when compared to ‘021-8774/93/3801/023/$3.00/1 © 1993 The Society of Analytical Psychology24 G.N. Brown the non-abused group. In addition, the sexual abuse victims were more likely to report dissociative experiences, sleep disturbance and nightmares, feelings of isolation, anxiety, muscle tension, problems with anger, sexual dysfunction, impulse to self-injure, and fear of men or women. He referred to this pattern of chronic symptomatology as a ‘Post Sexual Abuse Syndrome’, and pointed out the similarity to the phenomenology of Borderline Personality Disorder as described in the Diagnostic and Statistical Manual, third edition (APA 1980). CASE MATERIAL The story that I will now present is the history and therapy over six years of a female patient whose pattern of dysfunction included most of those symptoms in Briere’s list and who presented typical features of adolescent borderline personality disorder. Amy is the eldest of two daughters of a black father and a white mother. She was referred to me, aged 16 years, following a serious overdose of paracetamol. Her problems, primarily school-based to begin with, had escalated over the years from disruptive behaviour through fighting and damage to school property to alcohol and solvent abuse and stealing. Her referral followed a period of strife in her relationship with her mother, almost continuous intoxication and chaos culminating in the serious overdose. In the first assessment meeting she came with her mother who appeared fraught and depressed. Amy, on the other hand, displayed her ace card, a truly warming and beatific smile. She wore rather boyish clothes and was a little chubby. In a first indi- vidual session she presented herself with a mixture of serenity and good sense, saying she needed help to stop drinking. However, she added that she drank to be rid of her other self. ‘It’s as if there are two of me, the other one takes me over, a monster whom no one can help.” Amy was born when her mother was 19 years old and her sister followed eighteen months later. Her parents had never married and separated finally after a stormy relationship when Amy was about 10 years old. Her mother had been a struggling single parent for much of the time. She claimed never to have understood why Amy had been the object of such consternation at school. At home, she said, Amy had been a good and supportive child up to about 14 years of age. Since then their relationship had become a source of anguish and despair to her. After admission to the Adolescent Unit, Amy began tentatively to disclose a long history of sexual abuse. Her disclosures were made in the context of weekly individual psychotherapy sessions. ThisBorderline states 25 content did not begin to appear until some weeks had elapsed and continued to emerge intermittently over subsequent months. Disclos- ures revealed a pattern of sexually abusing relationships with men, from age 5 years up to the time of admission. She began with a peripheral anecdote about a park keeper, a stranger. When she was about 10 years old, her parents had separated, and to avoid her mother’s destructive misery she wandered sadly in a local park. The man appeared kind and friendly and took her into his keeper’s hut where he pressed her into a sexual act. This anecdote, the first disclosure of child sexual abuse she had ever made, has three levels of significance. First, as a statement about an external event. A communication of a fearfully kept, guilty secret. Second, it can be viewed as a communication about the transference. The therapist appears kind and invites the troubled girl into his room, but what are his intentions? How will the contact develop from here? Third, the anecdote can be viewed as a sort of screen memory. Like the content of a dream, it tells of an internal structure, of a pattern of object relationships. These differing levels of meaning, common to all communications when viewed psychodynamically, have a special importance in work with victims of child sexual abuse. The patient’s past experience of the transgression of boundaries by the actual behaviour of adults surpasses that of non-victims. The weight, in terms of internal versus external, has a different balance. The first level, that of the communication of a factual event, may have statu- tory child protection significance and therefore raise ethical dilemmas for a therapist. At the second level, the exploration of transference, the possibility that the therapist’s intentions are in fact sexual and that the interaction will proceed towards a sexual act is not only a fantasy. It is real possibility when viewed from the patient’s model of what happens in a dependent relationship with an adult male. This early phase of my work with Amy took place in the context of her admission to the more or less safe and holding environment of the in-patient therapeutic milieu. While the content of sessions, including the material which constituted disclosure of abuse, was fargely without affect, Amy’s behaviour on the ward included epi- sodes of destructive acting out, sleep disturbance, nightmares, and visual hallucinations: the manifestations of her other self. Escalation of these features both preceded and followed disclosure of past abuse. To begin with, Amy disclaimed any feelings associated with either session material or the disturbed behaviour. After a day in which she had continually disrupted nursing staff in their tasks until they began to feel angry, I suggested that she might be feeling angry inside. She considered this and responded, ‘I don’t have any feelings’, This intense dissociation from feeling states was pervasive and consistent.